Everything You Need to Know About Reimbursement For GUIDE Everything You Need to Know About Reimbursement For OMIDRIA

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<ul><li><p>REIMBURSEMENT GUIDE</p><p>Everything You Need to Know About Reimbursement For OMIDRIA</p></li><li><p>2</p><p>About OMIDRIA</p><p>OMIDRIA is the first and only FDA-approved drug that provides continuous intracameral delivery of NSAID and mydriatic/ anti-miotic therapy during cataract surgery1</p><p> OMIDRIA contains a non-steroidal anti-inflammatory drug, ketorolac, to prevent miosis and to reduce postoperative pain and an a1-adrenergic receptor </p><p>agonist, phenylephrine, to maintain ocular pupil diameter</p><p> OMIDRIA is easy to integrate into operating procedures:</p><p> Added preoperatively to irrigation solution1</p><p> No other preparation required </p><p> OMIDRIA is supplied as a concentrate in a clear, glass, single-patient-use vial </p><p>containing 4-mL of sterile solution1</p><p> OMIDRIA is reimbursed per vial, not per mL. Therefore, providers should use one </p><p>vial as the billing unit</p><p>INDICATIONS AND USAGEOMIDRIA is added to ophthalmic irrigation solution used during cataract surgery or intraocular lens replacement and is indicated for maintaining pupil size by preventing intraoperative miosis and reducing postoperative ocular pain.</p><p>IMPORTANT SAFETY INFORMATIONOMIDRIA (phenylephrine and ketorolac injection) 1% / 0.3% must be added to irrigation solution prior to intraocular use.</p><p>OMIDRIA is contraindicated in patients with a known hypersensitivity to any of its ingredients. Systemic exposure of phenylephrine may cause elevations in blood pressure.</p><p>Use OMIDRIA with caution in individuals who have previously exhibited sensitivities to acetylsalicylic acid, phenylacetic acid derivatives, and other non-steroidal anti-inflammatory drugs (NSAIDs), or have a past medical history of asthma.</p></li><li><p>Please see the Full Prescribing Information for OMIDRIA.</p><p>About This Guide</p><p>This guide provides information on pass-through, OMIDRIA coding, OMIDRIA reimbursement, and more This guide is designed to facilitate timely reimbursement by standardizing claim </p><p>submissions and ensuring appropriate reimbursement through proper billing and product coding*</p><p> Coverage and payment may vary by payer, contractual agreements, and site of service</p><p>* Information contained in this guide is provided as a reference for obtaining appropriate and accurate reimbursement for the use of OMIDRIA in eligible patients. Omeros does not guarantee reimbursement. OMIDRIAssure program services are subject to change without notice.</p><p>OMIDRIA has a unique billing code</p><p>C9447 Injection, phenylephrine and ketorolac, 4 ml vial </p><p>Important reminders </p><p> The OMIDRIAssure comprehensive reimbursement program provides assistance for financially eligible uninsured or government-insured patients and those with insufficient commercial insurance*</p><p> Questions related to a patients benefits or eligibility for cataract surgery or OMIDRIA should be addressed by calling the OMIDRIAssure Live Assistance Information Hotline at 1-877-OMIDRIA (1-877-664-3742), contacting your Omeros representative, or working directly with your payer provider representative</p><p> Consult your facility-specific payer contracts to determine whether OMIDRIA is paid separately from the packaged payment for cataract surgery</p><p>IMPORTANT SAFETY INFORMATION The most commonly reported adverse reactions at 2-24% are eye irritation, posterior capsule opacification, increased intraocular pressure, and anterior chamber inflammation.</p><p>Use of OMIDRIA in children has not been established.</p><p>Please see the Full Prescribing Information for OMIDRIA.</p><p>You are encouraged to report Suspected Adverse Reactions to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.</p></li><li><p>4</p><p>Medicare Part B Pass-through status allows reimbursement for OMIDRIA separate from the packaged </p><p>Ambulatory Payment Classification (APC) reimbursement for the surgical procedure</p><p> For pass-through drugs, Centers for Medicare &amp; Medicaid Services (CMS) sets the payment rate at Average Selling Price (ASP) plus 6%</p><p> Check the CMS website for current quarterly payment rates in the Hospital OPPS (Addendum B) or ASC Payments (Addendum BB) section</p><p> Payment rates are updated quarterly by CMS and, during the government sequester, 6% is reduced to 4.3%</p><p> There is no patient co-payment for OMIDRIA in the HOPD setting. In the ASC setting, the patient may be subject to a 20% co-payment</p><p> Approximately 90% of Medicare Part B patients have some form of supplemental/secondary insurance that covers co-payments3, </p><p> For government-insured patients with an uncovered out-of-pocket expense and who meet certain financial criteria, Omeros has established the Equal Access Patient Assistance Program as part of OMIDRIAssure, which allows patients to receive OMIDRIA at no cost; a free vial is sent to your facility prior to surgery</p><p> About Medicare Billing and Reimbursement</p><p>Pass-through status for OMIDRIA allows ASCs and HOPDs to bill Medicare and other payers for OMIDRIA using a Healthcare Common Procedure Coding System (HCPCS) code unique to OMIDRIA C9447 Injection, phenylephrine and ketorolac, 4 ml vial. The payment is over and above the facility fees paid to ASCs or to HOPDs for cataract surgery.</p><p>CY 2017 HCPCS and APC codes for OMIDRIA2</p><p>CY 2017 HCPCS CY 2017 long descriptor CY 2017 APC</p><p>C9447 Injection, phenylephrine and ketorolac, 4 ml vial 1663</p><p>*Status Indicator</p><p> Based on currently available information and subject to change without notice. Individual plan coverage, policies, and procedures may vary and should be confirmed. Omeros does not guarantee coverage or payment. </p><p> To be eligible for the Equal Access Patient Assistance Program, patients must be enrolled prior to surgery. For any patient eligible for the Equal Access Patient Assistance Program, (1) the facility receives a free vial of OMIDRIA prior to surgery and (2) the patients insurance carrier(s) should not be billed for OMIDRIA. OMIDRIAssure program services are subject to change without notice. </p></li><li><p>Please see the Full Prescribing Information for OMIDRIA.</p><p>Medicare Part C (Medicare Advantage) Like traditional Medicare Part B, Medicare Advantage plans will cover OMIDRIA, but </p><p>the payment rate may differ from traditional Part B or be subject to payer-specific facility contractual limitations</p><p> For a Medicare Advantage patient, the specific Medicare Advantage payer should be contacted in advance to determine the level of reimbursement for OMIDRIA </p><p> About Medicare Billing and Reimbursement</p><p>* To be eligible for the Equal Access Patient Assistance Program, patients must be enrolled prior to surgery. For any patient eligible for the Equal Access Patient Assistance Program, (1) the facility receives a free vial of OMIDRIA prior to surgery and (2) the patients insurance carrier(s) should not be billed for OMIDRIA. OMIDRIAssure program services are subject to change without notice.</p><p>EQUAL ACCESS </p><p>PATIENT ASSISTANCE PROGRAM*</p><p>Assistance for financially eligible uninsured or government-insured patients </p><p> Eligible patients* will receive OMIDRIA at no cost</p><p> Free vial will be sent to your facility prior to surgery </p><p> Application for free vial must be submitted 5 days prior to date of surgery</p><p> Please visit www.OMIDRIAssure.com for more details and to start enrolling patients today</p><p> For personalized help, call the OMIDRIAssure Live Assistance Information Hotline at 1-877-OMIDRIA (1-877-664-3742) 9 am6 pm ET, MondayFriday</p></li><li><p>6</p><p> About Commercial Insurance Billing and Reimbursement</p><p> Check if facility-specific payer contracts allow for separate payment of drugs, new technologies, and pass-through drugs</p><p> Confirm and verify payer payment/fee schedules for OMIDRIA</p><p> Verify acceptance of C-code and payer-specific use of appropriate revenue code</p><p>WE PAY THE DIFFERENCE COMMERCIALLY INSURED PATIENT REIMBURSEMENT PROGRAM</p><p>Assistance for patients with insufficient commercial insurance Omeros will pay your facility, on behalf of your patient, the difference between your </p><p>facilitys acquisition cost for OMIDRIA and the amount covered by your patients insurance*</p><p> The benefits of OMIDRIAssure apply even if the annual commercial deductible obligation has not yet been met</p><p> Please visit www.OMIDRIAssure.com for more details and to start enrolling patients today</p><p> For personalized help, call the OMIDRIAssure Live Assistance Hotline at 1-877-OMIDRIA (1-877-664-3742) 9 am6 pm ET, MondayFriday</p><p>Payer Contracts: Best Practices for Medicare Advantage** and Commercial Payers</p><p>* OMIDRIAssure program services are subject to change without notice. The We Pay The Difference Commercial Reimbursement Program patient benefit is not available for patients with any government insurance. Omeros does not guarantee reimbursement.</p><p>** Coverage and payment varies by Medicare Advantage plans.</p></li><li><p>Please see the Full Prescribing Information for OMIDRIA.</p><p>Helpful hints: best practices for claim submissions in general Make sure submissions are timely and accurate</p><p> Double-check codes and units</p><p> Verify Diagnosis codes and procedure codes</p><p> CPT, HCPCS, and revenue codes</p><p> NDC (depending on claim form)</p><p> Stay up to date on the payer and billing and coding trends</p><p> Pay close attention and double-check your work when creating claims</p><p> Follow up with payers after claims are submitted </p><p> About Commercial Insurance Billing and Reimbursement</p><p>Patient insurance benefits should be thought of in terms of primary and additional coverage to determine billable status Work with Omeros Reimbursement Team to determine billable status for your payers </p><p>Step 1: Primary Insurance</p><p>Step 2: Additional Insurance</p><p>Medicare C(Replacement or) </p><p>Advantage)</p><p>Medicare B(FFS or Legacy </p><p>Medicare)</p><p>Medicare Supplemental </p><p>(Medigap)</p><p>Secondary</p><p>Medicaid</p><p>Other</p><p>Commercial</p><p>Secondary</p><p>Medicare Part A/B</p><p>Other Government</p><p>Medicaid</p><p>Tricare / DOD</p></li><li><p> Ambulatory Surgery Center Sample CMS-1500 Paper Claim Form</p><p>APPROVED OMB-0938-1197 FORM 1500 (02-12) PLEASE PRINT OR TYPE</p><p>Information contained herein is provided as a reference for obtaining appropriate and accurate reimbursement. This content is for informational purposes only. Omeros does not guarantee that the use of the recommended codes will result in reimbursement. Providers may always contact the payer directly with reimbursement or billing questions. Contact 1-844-OMEROS1 (1-844-663-7671) for more information about how to submit for OMIDRIA reimbursement.</p><p>CPT is a registered trademark of the American Medical Association.</p><p>CPT = Current Procedural Terminology; ICD-10-CM = International Classification of Diseases, Tenth Revision, Clinical Modification; IOL = intraocular lens; NDC = National Drug Code.</p><p>Item 24D: Enter the unique Billing Code for OMIDRIA</p><p>Item 24D: Enter the applicable procedure code (e.g., 66984 for cataract surgery)</p><p>Item 21: Enter the Diagnosis Code(s) </p><p>Item 24B: 24 indicates an ASC</p><p>Enter all applicable patient information</p><p>If using miscellaneous J-code instead of using C-code for OMIDRIA based on instruction from payer, please include NDC on line 19</p><p>Item 24G: Enter the number of Units (vials)</p><p>Item 24F: Enter price for OMIDRIA from price schedule, including all applicable mark-ups</p><p>Item 33a: Entry of NPI Number is required</p><p>Item 24D: Enter the Modifier for left eye (LT) or right eye (RT)</p><p>Item 21: Enter 0 if using ICD-10-CM</p><p>04 01 2017 04 01 2017 24 66984 LT A XXX XX 1 1234567890 </p><p>.XXX</p><p>X</p><p>X</p><p>X X</p><p>X</p><p>123 45 6789A</p><p>SMITH, MARY</p><p>123 MAIN</p><p>ANYTOWN PA</p><p>ANY ASC456 ANY STREETPHILADELPHIA, PA 19103</p><p>04 01 2017 04 01 2017 24 C9447 A XXX XX 1 1234567890</p><p>123 456-7890</p><p>0</p><p>NDC# 62225-0600-04</p><p>8</p></li><li><p> Sample UB-04 Paper Claim Form</p><p>Information contained herein is provided as a reference for obtaining appropriate and accurate reimbursement. This content is for informational purposes only. Omeros does not guarantee that the use of the recommended codes will result in reimbursement. Providers may always contact the payer directly with reimbursement or billing questions. Contact 1-844-OMEROS1 (1-844-663-7671) for more information about how to submit for OMIDRIA reimbursement.</p><p>CPT is a registered trademark of the American Medical Association.</p><p>CPT = Current Procedural Terminology; ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; ICD-10-CM = International Classification of Diseases, Tenth Revision, Clinical Modification; IOL = intraocular lens; NDC = National Drug Code.</p><p> __ __ __</p><p>1 2 4 TYPEOF BILL</p><p>FROM THROUGH5 FED. TAX NO.</p><p>a</p><p>b</p><p>c</p><p>d</p><p>DX</p><p>ECI</p><p>1</p><p>2</p><p>3</p><p>4</p><p>5</p><p>6</p><p>7</p><p>8</p><p>9</p><p>10</p><p>11</p><p>12</p><p>13</p><p>14</p><p>15</p><p>16</p><p>17</p><p>18</p><p>19</p><p>20</p><p>21</p><p>22</p><p>23</p><p>1</p><p>2</p><p>3</p><p>4</p><p>5</p><p>6</p><p>7</p><p>8</p><p>9</p><p>10</p><p>11</p><p>12</p><p>13</p><p>14</p><p>15</p><p>16</p><p>17</p><p>18</p><p>19</p><p>20</p><p>21</p><p>22</p><p>23</p><p>A</p><p>B</p><p>C</p><p>A B C D E F G HI J K L M N O P Q</p><p>a b c a b c</p><p>a</p><p>b c d</p><p>ADMISSION CONDITION CODESDATE</p><p>OCCURRENCE OCCURRENCE OCCURRENCE OCCURRENCE SPAN OCCURRENCE SPANCODE DATE CODE CODE CODE DATE CODE THROUGH</p><p>VALUE CODES VALUE CODES VALUE CODESCODE AMOUNT CODE AMOUNT CODE AMOUNT</p><p>TOTALS</p><p>PRINCIPAL PROCEDURE a. OTHER PROCEDURE b. OTHER PROCEDURE NPICODE DATE CODE DATE CODE DATE</p><p>FIRST</p><p>c. d. e. OTHER PROCEDURE NPICODE DATE DATE</p><p>FIRST</p><p>NPI</p><p>b LAST FIRST</p><p>c NPI</p><p>d LAST FIRST</p><p>UB-04 CMS-1450</p><p>7</p><p>10 BIRTHDATE 11 SEX 12 13 HR 14 TYPE 15 SRC</p><p>DATE</p><p>16 DHR 18 19 20</p><p>FROM</p><p>21 2522 26 2823 27</p><p>CODE FROM</p><p>DATE</p><p>OTHER</p><p>PRV ID</p><p> THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.</p><p>b</p><p> .INFO</p><p>BEN.</p><p>CODEOTHER PROCEDURE</p><p>THROUGH</p><p> 29 ACDT 30</p><p>3231 33 34 35 36 37</p><p>38 39 40 41</p><p>42 REV. CD. 43 DESCRIPTION 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49</p><p>52 REL51 HEALTH PLAN ID</p><p>53 ASG.54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI</p><p>57</p><p>58 INSUREDS NAME 59 P.REL 60 INSUREDS UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.</p><p>64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME</p><p>66 67 68</p><p>69 ADMIT 70 PATIENT 72 73</p><p>74 75 76 ATTENDING</p><p>80 REMARKS</p><p>OTHER PROCEDURE</p><p>a</p><p>77 OPERATING</p><p>78 OTHER </p><p>79 OTHER </p><p>81CC</p><p>CREATION DATE</p><p>3a PAT.CNTL #</p><p>24</p><p>b. MED.REC. # </p><p>44 HCPCS / RATE / HIPPS CODE</p><p>PAGE OF</p><p>APPROVED OMB NO. 0938-0997</p><p>e</p><p>a8 PATIENT NAME</p><p>50 PAYER NAME</p><p>63 TREATMENT AUTHORIZATION CODES</p><p>6 STATEMENT COVERS PERIOD</p><p>9 PATIENT ADDRESS</p><p>17 STAT STATE</p><p> DX REASON DX 71 PPS </p><p>CODE</p><p>QUAL</p><p>LAST</p><p>LAST</p><p>National UniformBilling CommitteeNUBC</p><p>OCCURRENCE</p><p>QUAL</p><p>QUAL</p><p>QUAL</p><p>CODE DATE</p><p>A</p><p>B</p><p>C</p><p>A</p><p>B</p><p>C</p><p>A</p><p>B</p><p>C</p><p>A</p><p>B</p><p>C</p><p>A</p><p>B</p><p>C</p><p>a</p><p>b</p><p>a</p><p>b</p><p>XXX Refer to Payer Contract for Code C9447 1272 Sterile Supplies276 IOL V2632300 Laboratory360 Operating Room 66984370 Anesthesia 00142710 Recovery Room </p><p>Any Hospital Any Hospital 123 Any Street 123 Any Street Philadelphia, PA 19103 Philadelphia, PA 19103</p><p>John Doe 1234 Main Street Philadelphia, PA 19111</p><p>Doe, John Philadelphia PA 19111</p><p>1234 98765 0131 </p><p>1234 Main Street</p><p>03 20 1971 M 01</p><p>XXXX</p><p>2222222222</p><p> 2222222222 1G 1234569822 Smith David</p><p>Medicare</p><p>Doe, John 18 ABC1234567800 </p><p>B3 282N00000X</p><p>0</p><p>1 1</p><p>Y Y</p><p>Form Locator 17: Enter Patient Status </p><p>Enter all applicable patient information</p><p>Form Locator 4: Enter the 4-digit code that specifies place of service and submission type. For example, for HOPD, the first 3 digits are 013. The final digit is usually a 1, meaning one cla...</p></li></ul>